Ligament Problem: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested surgical services on an emergent or urgent basis. Findings: The physician reviewer found that at issue in this case is whether a prudent layperson in the patient’s circumstances would have sought immediate medical attention. California law defines an “emergency medical condition” as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patient’s health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part.

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for magnetic resonance imaging (MRI) of the left knee. MRI is the current gold standard for the assessment of soft tissue, chondral, and bony pathologies of the knee joint. The American College of Radiology guidelines for chronic knee pain report that “MRI is indicated for non-traumatic knee pain when pain is persistent and radiographs are non-diagnostic. It is not indicated before complete physical examination and radiography, or for the following conditions: severe degenerative joint disease, inflammatory arthritis, stress fracture, osteonecrosis, or chronic regional pain syndrome.” In this case, the patient did not present with chronic knee pain. However, the records indicate that he sustained a twisting injury with noted immediate instability of the left knee.

Where the denial was upheld

Nature of Statutory Criteria/ Case Summary: The enrollee requested authorization and coverage for ultrasound guided dextrose prolotherapy (CPT codes 20550, 76942 x1, J3490 x6 and J2001 x1). The enrollee has a diagnosis of right-sided tibialis posterior tendinitis. She has left knee pain from osteoarthritis. An ultrasound demonstrated increased mixed echogenicity of the right posterior tibialis tendon. There was significant fluid around the right posterior tibialis tendon. The enrollee received a right posterior tibialis tendon sheath Toradol injection. The injection helped her pain. She reportedly only experienced pain when running and with high impact activities, which she has avoided. The surgeon suggested a dextrose injection for pain management as the enrollee has failed conservative treatment.

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for imaging services. Researchers state, “Back and neck pain are ubiquitous in today’s society, a common cause of disability, and a large burden to healthcare costs. When conservative management of low back or neck pain fails, magnetic resonance imaging (MRI) is the imaging modality of choice to assess for underlying abnormality. Knowledge of spine anatomy and imaging features of degenerative changes allow for appropriate reporting and directs appropriate patient management.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for ligament problem was denied, the published record says the denial is worth fighting.